Provider Demographics
NPI:1831206754
Name:HAMILTON, GLENN D (MD)
Entity type:Individual
Prefix:
First Name:GLENN
Middle Name:D
Last Name:HAMILTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:7 QUIGLEY LN
Mailing Address - Street 2:
Mailing Address - City:GARNET VALLEY
Mailing Address - State:PA
Mailing Address - Zip Code:19061-1234
Mailing Address - Country:US
Mailing Address - Phone:610-358-9965
Mailing Address - Fax:775-923-9397
Practice Address - Street 1:777 DELAWARE PARK BLVD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19804-4122
Practice Address - Country:US
Practice Address - Phone:302-994-3166
Practice Address - Fax:775-923-9397
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-24
Last Update Date:2009-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD042891E207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
0701881000OtherKEYSTONE
PA01873711Medicaid
2045582OtherBCBS PA
01-24638OtherEVERCARE
054171Medicare PIN
054171R3WMedicare PIN
01-24638OtherEVERCARE
F75975Medicare UPIN